PHYSIOTHERAPY CANADA

Shannon et al. Do Paediatric Physiotherapists Promote Community-Based Physical Activity for Children and Youth with Disabilities? A Mixed-Methods Study 69 of responses from 116 participants. The participants’ age Table 1 Participants’ Age, Years of Overall Clinical Experience, and Years ranges, years of clinical practice experience, and years of Paediatric Experience (N = 116) of paediatric-specific clinical experience are reported in Table 1. The mean number of years of physiotherapy Participant characteristics No. (%) practice was 17.83 (SD 11.44), with a mean of 10.84 (SD https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 10.44) years working in paediatrics. The distribution of Age range, y 2 (1.7) participants by province is reported in Table 2. 21–25 31 (26.7) 26–30 1 (0.9) Participants reported their highest level of educa­ 31–35 19 (16.4) tion as bachelor’s degree (66; 56.9%), master’s degree (47; 36–40 19 (16.4) 40.5%), or doctorate (3; 2.6%). The majority were clini­ 41–45 20 (17.2) cians (113; 97.4%), researchers (10; 8.6%), and adminis­ 46–50 9 (7.8) trators (9; 7.8%). Other roles (4; 3.4%) included educator, 51–55 5 (4.3) clinical coordinator, and research therapist. Roles were 56–60 9 (7.8) not mutually exclusive: of the therapists, 19.0% reported 61–65 1 (0.9) multiple roles. Respondents worked primarily in public 66+ settings (73; 62.9%), including hospitals, rehabilitation 17 (14.8) centres, child development centres, and schools. The Clinical experience, y* 21 (18.3) remainder worked in private clinics (27; 23.3%) or com­ < 1–5 17 (14.8) bined private and public roles (16; 13.8%). Areas of prac­ 6–10 19 (16.5) tice for clinician respondents included neurology (30; 11–15 18 (15.7) 25.9%), orthopaedics (25; 21.6%), developmental ser­ 16–20 6 (5.2) vices (49; 42.2%), cardiorespiratory (3; 2.6%), and mixed 21–25 5 (4.3) caseload (43; 37.1%). The majority of participants worked 26–30 9 (7.8) with children with physical and intellectual disabilities 31–35 2 (1.7) (87; 75.0%). 36–40 1 (0.9) 41–45 What were the perceived benefits of community-based physical 46–50 40 (34.5) activity programmes? 28 (24.1) Clinical paediatric experience, y 18 (15.5) Participants were asked to identify the top three < 1–5 11 (9.5) benefits of community-based physical activity. They 6–10 8 (6.9) most frequently identified social benefits (80; 69.0%), 11–15 4 (3.4) followed by physiological benefits (75; 64.7%) and the 16–20 1 (0.9) development of self-confidence or self-efficacy (63; 21–25 6 (5.2) 54.3%). Other top three benefits included gross motor 26–30 skill development (59; 50.9%), development of inde­ 31–35 pendence (28; 24.1%), sense of achievement or accom­ 36–40 plishment (27; 23.3%), and cognitive development (14; 12.1%). * N = 115, reflecting missing data. To what extent did the physiotherapists engage in promoting Table 2 Geographical Distribution of Survey Participants (N = 116) community-based physical activity as part of their role? Province or territory No. (%) A large proportion of the participants (80; 69.0%) believed that promoting community-based physical Alberta 44 (37.9) activity was a crucial or major role for physiotherapists. British Columbia 5 (4.3) Only 6 (5.2%) participants did not consider community- Manitoba 18 (15.5) based physical activity promotion as part of the phys­ New Brunswick 15 (12.9) iotherapy role, and 32 (27.6%) considered the role to be Newfoundland and Labrador 7 (6.0) minor. Although approximately half the participants Northwest Territories 0 (0.0) reported that children, families, or both asked them about Nova Scotia 19 (16.4) community physical activity programmes often or con­ Nunavut 0 (0.0) sistently (32; 27.6%) or occasionally (37; 31.9%), a large Ontario 4 (3.4) proportion reported that families rarely (32; 27.6%) Prince Edward Island 0 (0.0) or never (15; 12.9%) did. The majority of participants Quebec 2 (1.7) (89; 76.7%) indicated that they recommended commu­ Saskatchewan 2 (1.7) nity-based physical activity programmes to children Yukon 0 (0.0)

70 Physiotherapy Canada, Volume 73, Number 1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 and families (Table 3). Both those who worked in public role to be providing information and connecting fami­ lies to community-based physical activities. The latter settings and those who worked in private settings were perspective appeared to be deeply rooted in personal values: equally likely to recommend such programmes (21 = 2.34, p = 0.126). Therapists with less than 6 years of paediatric My passion for physio also then went beyond my job. … I saw [promotion] being my responsibility – being pas­ practice were less likely to recommend community-based sionate about it outside of the job. And that’s sort of the physical activity programmes (24 = 40.46, p < 0.001) than way I’m orientated. more experienced therapists, as were therapists with less clinical experience overall (24 = 14.11, p < 0.001). I do see [promotion] as part of my role, and especially in the early years, because families are just starting their Table 3 Therapists’ Recommendation Practices by Years of Paediatric journey. They’re just starting to explore recreation as a Experience (N= 116) family, and it’s nothing really formalized yet, so I think it’s well within my scope to introduce – “Hey, there’s Recommended physical activity some gymnastics clubs here; there’s a dance club; what about swimming lessons?” So, I do see it as my role. Years of experience n programmes, no. (%) Gathering and sharing information with families occured 0–10 68 43 (63.2) at the discretion of individual therapists, resulting in pro­ 11–20 29 27 (93.1) motion strategies that were inconsistent and influenced 21–30 12 12 (100.0) by practice settings: 31–40 7 7 (100.0) Total 116 89 (76.7) And I think many physical therapists would attach phys­ ical activity to our roles, it’s just how do we do it – how What did the therapists perceive were the barriers to accessing do we, in an ideal world, bring that together so it’s not community physical activity programmes? just potentially hit and miss, depending [on which ther­ apist] has the most interest in it. Because sometimes it Most respondents (113; 97.4%) believed that there is a hit and miss, depending where you’re working. were barriers to accessing community-based physical activity programmes. Financial barriers were perceived to Other influences on the therapists’ ability to promote be the greatest challenge (81; 69.8%), followed by lack of community physical activity were discussed, including qualified staff (64; 55.2%), inadequate transportation (51; role expectations that varied by practice setting and case- 44.0%), caregivers’ psychological barriers (50; 43.1%), lack load demand. This therapist discussed the context that of physical accessibility (47; 40.5%), and difficulty access­ influenced her ability to promote physical activity: ing information (40; 34.5%). Other barriers included children’s psychological barriers (29; 25.0%) and rigid I saw my role different[ly], depending on where I was eligibility criteria that excluded children with disabilities at. I mean in the educational model, I felt the oppor­ (21; 18.1%). tunity to have the collaboration with the phys ed con­ sultants, and there was a strength building, aligning Focus groups activity with our role as a physical therapist and mak­ Ten therapists participated in four focus groups (2–4 ing sure that they were safe and moving well in school. In health, I found it to be a bit more challenging … your per group); this small group size allowed us to maximize roles and expectations can sometimes differ. Not to say participant engagement and ensure that everyone had that I didn’t always value it, but sometimes when you adequate opportunities to participate in discussions.20 were in the context of something more medical … it Three themes were developed related to the physiother­ was hard to add that component. It’s hard sometimes apists’ roles and practices related to physical activity pro­ to keep up on what all the programmes are. And so I’ve motion: (1) lack of clarity regarding the physiotherapy always felt that clinics and even in a tertiary care rehab role, (2) “it’s not easy” – challenges related to community- hospital, could have a lot of value in having someone based physical activity promotion, and (3) one size does play that role a little bit more definitively. not fit all. Programme mandates and funding sources also influ­ Lack of clarity regarding the physiotherapy role enced the therapists’ ability to promote physical activity Participants expressed diverse opinions about the as part of their role: role of physiotherapy related to facilitation of com­ Maybe it does come down [to] who’s paying for the munity-based physical activity. All agreed that giving service. If it’s paid for by the school district and their families information about community programmes was a collective responsibility of the health care team, but some questioned the value of allocating physio­ therapy resources to these activities. Conversely, other therapists considered the most meaningful part of their

Shannon et al. Do Paediatric Physiotherapists Promote Community-Based Physical Activity for Children and Youth with Disabilities? A Mixed-Methods Study 71 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 mandate is not to go beyond that, then that’s all they programmes in their communities; one therapist pro­ can manage. … They only have so many hours and that posed that a centralized service would help families nav­ isn’t in their mind that they should be doing that, it igate programmes, mitigate the confusion among health doesn’t fit into their hours allowed to the patient. care professionals about their role, and ensure that fami­ lies received thorough and timely information. Some therapists described a lack of managerial support for allocating resources to promoting community-based My dream state would be that there would be … some­ physical activity, particularly in hospital settings, where where central – you need help figuring out what you this aspect of practice was often not considered a priority want to do and finding the programme that fits you because of the inability to provide services offsite or orga­ and is in your life and go and talk to this social worker– nizational administrative barriers: type physiotherapist that’s going to really be able to link you and keeps programmes up-to-date. Sort of You know if we could have the staffing that we could some centralized bureau of participation. I don’t even take them off site as one of their treatment sessions, know what that looks like. and – and the support of, of management to – to do that. Because I think when we, the parents experience “It’s not easy”: challenges related to community-based physical it, then they’re more likely to – to do it, and feel com­ activity promotion fortable with doing it. But I know that’s an ideal world, I don’t think that will ever happen. Therapists mentioned lack of time as a barrier to pro­ moting physical activity. The time required to stay current We always have so many red tape issues here. … Even with local programmes, schedules, and timelines was just [having organizations] coming to tell us what’s this often thought to be excessive, given other responsibilities. about and maybe not even play games for the kids, but In the urban centres, many programmes were available, just giving us more info. … Like who to connect [families] some with specific mandates and eligibility criteria. Ther­ to, to figure out if that’s even a possibility or [something] – apists often learn about changes to programmes via word our manager would support that. of mouth from parents, resulting in individualized knowl­ edge and a hit-or-miss approach to information sharing Regardless of the barriers, many therapists found innova­ with families. Moreover, the therapists often reported tive ways of ensuring that children had opportunities to that they did not have confidence in either the accuracy engage in physical activity. One therapist who worked in or the extent of their knowledge of community-based a rural area initiated her own dance programme for chil­ programmes: dren with disabilities. Other therapists took time outside their paid work hours to accompany children to facilities: I think really and truly it takes a lot to do what we do in the short time that we get with our kids, that some­ I have taken [children] to the rec centres … and showed times you just get through what you have to do kind them how to [swim], and [I have] gone to the gym with of as your [physiotherapist] … role. Thinking about the people who have asked if I would come and show them other stuff can be challenging. And it’s a lot of research how to use the equipment. and it’s a lot of staying up to date on programmes too, because things change really quickly. So, it is time con­ Although some participants thought that therapists suming, so I could see that as being a limiting factor. should spend time outside working hours increasing their knowledge about available programmes, others advo­ Organizational capacity for community connection cated for formalizing the promotion of physical activity as was also a common discussion point. The therapists part of their role within the health care system and allo­ reported that they were likely to promote familiar pro­ cating the appropriate resources and dedicated work time grammes, those run by someone with whom they had had to this role. Participants also discussed where responsi­ previous face-to-face interactions. If they were unable to bility for sharing knowledge of community programmes connect directly with programme representatives, they and resources lies among the various members of the were less likely to recommend those programmes. Sim­ health care team. Some suggested that anyone who had ilarly, if community physical activity organizations did contact with children and families should be connecting not readily share information about their programmes, them with programmes, and others thought that sharing therapists’ knowledge was variable; they often perceived information was a role best left to social workers and rec­ that their knowledge was inadequate to pass on to fam­ reation therapists: ilies. Linkages with community programmes were there­ fore seen by some as the most effective way to ensure that At a place like the [hospital], you have other people [who] families received accurate information: are also working on those same things, so potentially the physio’s role in that is not as involved as another setting. Having some of those organizations come in and talk to you – you know, the pre-kindergarten programmes An expanded role for the health care team would ensure where we have all of these kids who have different that more families had information about resources and

72 Physiotherapy Canada, Volume 73, Number 1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 challenges – come in and do a session called a family- them. … I’ve often thought, how can we offer support oriented programming session. Where they could share to those people? … It just seems like we don’t have a information about what their programme offers so that way that we can teach that programme to be adapted families don’t have to do all that work to try and track for that one kid … but for sure that kid could go there. down. And they know a little bit more about what the wait lists are, ’cause sometimes that’s an issue, too. In addition to this discussion about therapists’ potential role in increasing community capacity, therapists dis­ The therapists were also concerned that placing respon­ cussed the need to have programmes that ensure access sibility on families for researching programmes resulted to adequately trained staff who can facilitate participa­ in a lower likelihood that they would enrol their chil­ tion for all children. dren in those programmes. A common solution to the knowledge gap across all focus groups was programme Participants reported feeling uncomfortable recom­ exposure and promotion, especially in schools and reha­ mending programmes with eligibility criteria related bilitation centres (including secondary and tertiary care). to intellectual functioning. Because physiotherapists In-person education sessions could be key to familiar­ focus on physical functioning, therapists had often not izing therapists with programmes because the sponsor­ discussed intellectual capacity directly with families ing organizations would provide first-hand information, of younger children, and introducing the topic of pro­ rather than therapists navigating websites or finding out grammes geared to children with intellectual disabilities through word of mouth. In addition, demonstration and seemed inappropriate and awkward. Many children do sport days were suggested as a way to familiarize thera­ not receive cognitive assessments until Grade 3 or 4, so pists with programmes because seeing programmes in discussions about children’s cognitive abilities were often action was important for understanding participant “fit” limited, and therapists were therefore less likely to sug­ versus simply being knowledgeable about eligibility crite­ gest a programme that included cognitive ability as an ria. Therapists, however, were often not permitted to con­ eligibility criterion: duct off-site visits that they considered to be beneficial for ensuring children and families had the most effective I am uncomfortable at times deciding on Special supports and equipment in place. Olympics Canada specifically as its perception is one of participation for those experiencing an intellectual [Sportball] can kind of promote their programme and disability. How may families perceive this? I always try again make it more accessible because the kids have to give well-rounded options based on their location, tried it, the families have seen it. … And then it’s like, resources, interests, the child’s interests, and activities “Hey, come and sign up; this is the requirement, this is that families like to do, for example, outdoors, commu­ what you need to do.” … Yeah, it’s familiar. It’s that face- nity programming options, one-on-one supports or to-face interaction that makes a big difference. group activities. I basically try to be encouraging and allow family choice. So, I went to see [dance programme] last week for the first time. Didn’t even know it existed. Amazing One size does not fit all programme. I would now, now that I’ve seen it here The participants valued both specialized and inclusive and I’ve experienced this, and I see what programmes they offer, I would for sure offer this to my patients. programmes and articulated their thoughts about the But again, it’s just there’s so many – so many places out unique benefits and challenges of both models. Inclu­ there that you just don’t know exist or would be appro­ sive programmes can be challenging when varying levels priate until you actually see it. of abilities exist within a group because the discrepancy among children’s capabilities can interrupt meaningful In addition to lack of time and the constraints related participation, resulting in some children being excluded. to access to information, therapists reported being con­ Some specialized programmes for children with simi­ cerned about the capacity of community-based pro­ lar abilities and skill levels offer excellent opportunities grammes to provide supports for children with a wide for skill development and competitive play. Some focus range of abilities. They also expressed concern about the group participants argued that specialized groups could lack of linkages between their workplaces and commu­ be more social and create a sense of belonging, which nity programmes: they believed to be inherently inclusive from the perspec­ tive of a child: The reality is that there’s 10 million programmes in [this city] and this child may fit in that programme, but that It’s not about that [child] needs to be in the hockey pro­ programme might be afraid to have them. … We don’t gramme when [child]’s not going to be able to skate. get phone calls from those programmes saying, I have You know like that’s not [what it’s] about – it’s not about a [child] who was wearing a brace, can he be [taken] being the bystander, it’s still about being part of that. out of it? There’s not a way of us communicating with But we do need some segregated programmes and there’s nothing wrong with that, absolutely nothing.

Shannon et al. Do Paediatric Physiotherapists Promote Community-Based Physical Activity for Children and Youth with Disabilities? A Mixed-Methods Study 73 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 A programme that’s set up to be inclusive, and is sup­ Formal supports and resources embedded in health posed to be able to meet everybody’s needs, and that care organizations could take the form of having up-to­ [has] the diversity of – of physical and cognitive, and date, centralized information repositories; facilitating behavioural – it’s a mix that’s really hard to, to make any­ family-to-family connections to support sharing infor­ one happy. And then those kids who are mildly involved mation; and allocating resources to ensure that thera­ but can’t really manage in another dance class, they pists are able to attend physical activity programmes don’t want to be with someone who’s going to come and and facilities in their community. Broadening the scope [display inappropriate behaviour toward] them. of their role to ensure face-to face contact with com­ munity organizations and therefore the ability to cre­ I find there’s value in both, but it depends on what the ate connections with those programmes could increase actual goal is of what you’re trying to achieve – with the likelihood that therapists will recommend them to that programme, with that child. Right? So, if it is for families. In addition, formal supports within organi­ social participation, for a child on the [autism] spec­ zations could reduce knowledge disparities that exist trum, or if it’s for learning social skills from another among therapists, and they could be effective in bridg­ child, or learning a “my turn, your turn” type of thing. ing the gap between rehabilitation and community pro­ Then maybe an inclusive … environment’s better. But grammes.27 It has previously been reported that families if you’re trying to teach specific skills and more one- may find this transition intimidating;28 therefore, pro­ on-one, then maybe the specialized would work. grammes designed to connect therapists and commu­ nity programmes could bolster families’ confidence in Although the therapists clearly articulated the bene­ addition to helping those programmes develop strate­ fits of inclusive programmes, they were also concerned gies for including children with disabilities. The concept about stigmatization. For example, one participant felt of rehabilitation clinicians becoming a bridge between uncomfortable about a dance programme for children therapy services and physical activity in the community with disabilities she had initiated. However, she thought has been proposed by others,29 specifically in the Cana­ that it fostered an important sense of community among dian context in Ontario.30 the children who participated: Therapists with less than 6 years of paediatric clinical It makes me a little uncomfortable that it’s as – that it’s experience were less likely to recommend community still a programme rather than kids being able to partic­ physical activity programmes to families. It is possible that ipate wherever they are able. But it allows them to have new paediatric therapists are focused on practising fun­ a chance to be a part of something, in a way that is – damental clinical skills in the first few years of their prac­ they feel good about themselves and … they get really tice rather than expanding their knowledge of community interesting experiences that they might not be getting programmes. It is also possible that links with community otherwise … they’re building relationships in the com­ physical activity programmes are not emphasized in ther­ munity as well. So as much as it still makes me a little apists’ educational programmes. Because learning about uncomfortable that it’s not really inclusive, it is starting programmes is time consuming and likely occurs over to be more about community than it is about that class. several years, this finding highlights the importance of supporting therapists, particularly those who are early in Overall, the therapists agreed that their role was to provide their paediatric careers, and creating links early in physio­ families with options and that the choice of programme therapy education programmes. Embedding community depended largely on the goals of the child and family. programme visits, presentations, or both into staff orien­ tations; allowing time to attend community programmes; DISCUSSION and ensuring that new staff have senior mentors may also Paediatric physiotherapists are in a unique position to facilitate information sharing. promote physical activity among youth with disabilities.26 Engaging in community-based physical activity from a Although the majority of the participants in this study general health promotion perspective could also involve agreed with this statement and identified promoting increased efforts at the organizational level to increase community-based physical activity as part of their phys­ capacity among community programmes. Strategies could iotherapy role, it was clear that there was a lack of formal include collaboration with community organizations to organizational supports for effectively fulfilling this role increase their capacity related to working with children and a lack of agreement about what the role should entail. and youth with disabilities. Such efforts should not focus This disconnect is not confined to paediatrics because on medicalizing community physical activity but on therapists in other specialized areas of practice value enhancing opportunities for meaningful participation for physical activity but do not actively promote it.16 This all children. Other Canadian studies conducted in Alberta study confirms that therapists’ lack of information about and Ontario have highlighted barriers to accessing com­ community programmes hinders their ability to ensure munity facilities.8,30,31 It is therefore important that fami­ that families are informed about their options; families lies are aware of their options and that facilities are aware likely do not have equitable access to information.

74 Physiotherapy Canada, Volume 73, Number 1 https://utpjournals.press${contentReq.requestUri} - Horizon College Physiotherapy <[email protected]> - Friday, February 12, 2021 2:48:19 AM - IP Address:43.246.243.71 of supports needed to ensure successful access to their analysis processes resulted in participants and research­ programmes.30 ers co-constructing the results. Although this is not con­ sidered to be a limitation of qualitative research, it should Physiotherapists could play a lead role in working with inform the readers’ interpretation of the results. families and community organizations to recommend physical supports and adaptations. Using a physical liter­ KEY MESSAGES acy model that addresses motor skills, motivation, and social and cognitive components,19 physical therapists What is already known on this topic could help develop children’s movement competence and Participating in physical activity is important for all confidence before they apply their specific sport skills in the community. This approach may better prepare chil­ children, but particularly for children with disabilities. dren for sport and physical activity in the community They experience more significant barriers than their by exposing them to different activities while nurturing able-bodied peers. their self-efficacy and motivation. Working in collabora­ tion with other professionals, including social workers What this study adds and recreation therapists, physiotherapists could ensure Despite placing a high value on the promotion of phys­ that families find a good fit for physical activities given their resources and preferred activities. Development of ical activity, therapists reported being limited in their formalized linkages to facilitate transition to community ability to engage in promotion activities: they lacked infor­ sport and physical activity at the organizational level mation about community programmes, they perceived may also promote more effective entry into physical decreased organizational capacity in certain practice set­ activity and sport for some children. tings, and lack of time was a significant constraint. CONCLUSION REFERENCES This study highlights the lack of clarity about the role 1. Larson RW. Toward a psychology of positive youth development. of physiotherapy in promoting community-based physi­ Am Psychol. 2000;55(1):170–83. https://doi.org/10.1037/0003­ cal activity for children with disabilities. Our participants 066x.55.1.170. Medline:11392861 acknowledged the importance of ensuring that families have adequate information but also that the tasks related 2. 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